Rédacteurs : Olivier Goret, Johan Nguyen, Claude Pernice, Henri Truong
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Ci-dessous, les différences entre deux révisions de la page.
| Les deux révisions précédentes Révision précédente Prochaine révision | Révision précédente | ||
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acupuncture:evaluation:rhumatologie - orthopedie:18. genou douloureux [28 Dec 2023 18:39] Nguyen Johan [1.2.4.3. Zhan 2018 ☆] |
acupuncture:evaluation:rhumatologie - orthopedie:18. genou douloureux [06 Mar 2024 07:59] (Version actuelle) Nguyen Johan [1.2.12.1. Shi 2021] |
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| - | === Tian 2022 ☆☆☆ === | + | === Tian 2022 RETRACTED === |
| - | Tian H, Huang L, Sun M, Xu G, He J, Zhou Z, Huang F, Liu Y, Liang F. Acupuncture for Knee Osteoarthritis: A Systematic Review of Randomized Clinical Trials with Meta-Analyses and Trial Sequential Analyses. Biomed Res Int. 2022 Apr 21;2022:6561633. https://doi.org/10.1155/2022/6561633 | + | <color #ed1c24>RETRACTED</color>. Tian H, Huang L, Sun M, Xu G, He J, Zhou Z, Huang F, Liu Y, Liang F. Acupuncture for Knee Osteoarthritis: A Systematic Review of Randomized Clinical Trials with Meta-Analyses and Trial Sequential Analyses. Biomed Res Int. 2022 Apr 21;2022:6561633. https://doi.org/10.1155/2022/6561633 |
| ^Background|Knee osteoarthritis (KOA) can cause chronic pain and seriously affect the quality of patient lives. The continued emergence of high-quality RCTS requires us to update the quality of evidence. This study aims to evaluate the efficacy of acupuncture for KOA patients and calculate the required information size (RIS) to determine whether further clinical studies are required.| | ^Background|Knee osteoarthritis (KOA) can cause chronic pain and seriously affect the quality of patient lives. The continued emergence of high-quality RCTS requires us to update the quality of evidence. This study aims to evaluate the efficacy of acupuncture for KOA patients and calculate the required information size (RIS) to determine whether further clinical studies are required.| | ||
| ^Methods| We searched PubMed, Embase, WOS, CBM, CNKI, VIP, WHO ICTRP, ChiCTR, and Grey literature to collect randomized controlled trials (RCTs) of acupuncture for KOA from inception to December 2021. A meta-analysis was performed according to the Cochrane systematic review method by using Review Manager 5.4 and TSA 0.9.5.10 beta, and GRADE was used to evaluate the quality of the evidence. Trial sequential analysis was used to control random errors and calculate the required information size.| | ^Methods| We searched PubMed, Embase, WOS, CBM, CNKI, VIP, WHO ICTRP, ChiCTR, and Grey literature to collect randomized controlled trials (RCTs) of acupuncture for KOA from inception to December 2021. A meta-analysis was performed according to the Cochrane systematic review method by using Review Manager 5.4 and TSA 0.9.5.10 beta, and GRADE was used to evaluate the quality of the evidence. Trial sequential analysis was used to control random errors and calculate the required information size.| | ||
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| === Comparison of acupuncture techniques === | === Comparison of acupuncture techniques === | ||
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| == Lee 2023 (acupotomy vs acupuncture) == | == Lee 2023 (acupotomy vs acupuncture) == | ||
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| ^Conclusion| Our findings indicated that acupotomy was a more effective treatment for knee osteoarthritis than acupuncture. However, most of the included RCTs had moderate risk of bias, meaning that more high-quality RCTs were needed.| | ^Conclusion| Our findings indicated that acupotomy was a more effective treatment for knee osteoarthritis than acupuncture. However, most of the included RCTs had moderate risk of bias, meaning that more high-quality RCTs were needed.| | ||
| - | == Ye 2022 == | ||
| - | Ye C, Zhou J, Wang M, Xiao S, Lv A, Wang D. The Effectiveness Comparison of Different Acupuncture-Related Therapies on Knee Osteoarthritis: A Meta-Analysis. Evid Based Complement Alternat Med. 2022 Jun 30;2022:2831332. https://doi.org/10.1155/2022/2831332 | + | == Ma 2023 (Network meta-analysis) == |
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| + | Ma W, Zhang CY, Huang X, Cheng W. Network meta-analysis of 7 acupuncture therapies for knee osteoarthritis. Medicine (Baltimore). 2023 Oct 27;102(43):e35670. https://doi.org/10.1097/MD.0000000000035670. | ||
| + | ^Objective| With the progression of society aging demographic, the prevalence of knee osteoarthritis (KOA) continues to rise steadily, exerting a significant impact on individuals' quality of life. Acupuncture therapy has garnered extensive utilization in the management of osteoarthritis; however, a comprehensive systematic review integrating acupuncture with traditional Chinese medicine remains absent. This study compared the clinical efficacy of 7 acupuncture methods (electroacupuncture, conventional acupuncture, warm needle, floating needle, fire needle, needle knife, and silver needle) for the treatment of KOA through a network meta-analysis.| | ||
| + | ^Methods| This study examined the databases-PubMed, EMbase, The Cochrane Library, the China Biology Medicine, Chinese Journal Full-text Database, Wanfang Database, and VIP Database-for randomized controlled trials of the 7 methods for KOA treatment. The search time spanned from the database establishment to March 5, 2022. The primary outcome indicator was the total effective rate, and the secondary outcome indicator was the visual analog scale. After the layer-by-layer screening, the quality of the literature was assessed using the Cochrane systematic reviewer manual 5.1.0 bias risk assessment tool for randomized controlled trials. After data extraction, the R4.0.1 software was used for network meta-analysis.| | ||
| + | ^Results| Based on the network meta-analysis, the ranking of interventions based on the surface under the cumulative ranking curve for the total effective rate is as follows: silver needle (0.99) > floating needle (0.97) > needle knife (0.66) > fire needle (0.56) > warm needle (0.44) > conventional acupuncture (0.35) > electroacupuncture (0.13). Regarding the improvement in visual analog scale scores, the surface under the cumulative ranking curve ranking is as follows: silver needle (0.97) > conventional acupuncture (0.67) > needle knife (0.64) > floating needle (0.51) > warm needle (0.44) > fire needle (0.14) > electroacupuncture (0.09).| | ||
| + | ^Conclusion| Based on the network meta-analysis, silver needle therapy emerged as the most efficacious and analgesic intervention for KOA. Nevertheless, given the notable variations in the quality and quantity of studies encompassing diverse treatment modalities, the findings of this research necessitate further substantiation through forthcoming high-quality multicenter, large-sample, randomized double-blind trials.| | ||
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| + | == Wang 2023 == | ||
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| + | Wang Z, Xu H, Wang Z, Zhou H, Diao J, Zhang L, Wang Y, Li M, Zhou Y. Effects of externally-applied, non-pharmacological Interventions on short- and long-term symptoms and inflammatory cytokine levels in patients with knee osteoarthritis: a systematic review and network meta-analysis. Front Immunol. 2023 Dec 14;14:1309751. https://doi.org/10.3389/fimmu.2023.1309751 | ||
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| + | ^Backgound| With the continuous development of clinical medicine, an increasing number of non-pharmacological interventions have been applied for the treatment of knee osteoarthritis (KOA), with the results of several recent randomized controlled trials (RCTs) showing that a variety of externally-applied, non-pharmacological interventions (EANPI) can improve symptoms and inflammation in patients with KOA. However, the relative benefits and disadvantages of non-drug therapies remain uncertain, and an optimal treatment strategy has not yet been determined.| | ||
| + | ^Objective| This study applied network meta-analysis (NMA) to compare and rank the effectiveness of EANPI on the short- and long-term clinical symptoms and inflammatory cytokine levels in patients with KOA.| | ||
| + | ^Methods| Two independent researchers searched online databases and performed manual retrieval of related citations to identify RCTs that met the selection criteria for the network meta-analysis. These researchers retrieved studies indexed from database inception to August 2023 and performed data extraction and assessment of the risk of bias.| | ||
| + | ^Results| The analysis included 80 RCTs involving 8440 participants and nine externally-applied, non-pharmacological therapies, namely extracorporeal shock wave, radiofrequency, acupotomy, laser therapy, Tuina therapy, kinesio taping, electroacupuncture, platelet-rich plasma injection, and ozone therapy. The treatment courses ranged from 1 to 12 weeks, with follow-up periods ranging from 4 to 24 weeks. The results of the NMA indicated that each non-drug therapy was superior to sham intervention in improving all outcome indicators. Except for the visual analog scale (VAS) and Western Ontario MacMaster (WOMAC) pain outcomes, all non-drug therapies had better efficacy than pharmacological treatments. For short-term VAS and tumor necrosis factor-alpha (TNF-α), extracorporeal shock wave performed better than other therapies (90.2% and 85.2% respectively). Radiofrequency therapy may be the most promising method to reduce long-term VAS, short- and long-term WOMAC pain, and interleukin (IL)-1β level (84.8%, 97.8%, 90.1%, 94.8% respectively). Tuina therapy may be a significant choice for short- and long-term outcomes of WOMAC function and range of motion (ROM).| | ||
| + | ^Conclusions| The results of the comprehensive comparison of the outcome indicators in 9 different EANPI indicated that radiofrequency and Tuina therapy were more effective and consistently ranked high in improving clinical symptoms in the short and long term. Radiofrequency is effective at relieving pain, and Tuina therapy can be given priority for treatment when hypofunction is the main symptom. EANPI to improve pain symptoms may be related to the regulation of inflammatory cytokine levels, which may be a potential mechanism of action.| | ||
| + | == Ye 2022 RETRACTED == | ||
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| + | * <color #ed1c24>Retracted</color>: The Effectiveness Comparison of Different Acupuncture-Related Therapies on Knee Osteoarthritis: A Meta-Analysis. Evid Based Complement Alternat Med. 2023 Jul 19;2023:9892726. https://doi.org/10.1155/2023/9892726 | ||
| + | * Ye C, Zhou J, Wang M, Xiao S, Lv A, Wang D. The Effectiveness Comparison of Different Acupuncture-Related Therapies on Knee Osteoarthritis: A Meta-Analysis. Evid Based Complement Alternat Med. 2022 Jun 30;2022:2831332. https://doi.org/10.1155/2022/2831332 | ||
| ^Objective| This meta-analysis aims to assess the efficacy of acupuncture-related therapy on knee osteoarthritis (KOA) patients.| | ^Objective| This meta-analysis aims to assess the efficacy of acupuncture-related therapy on knee osteoarthritis (KOA) patients.| | ||
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| ^Results| A total of 3239 patients from 31 RCTs were finally included. Meta-analysis showed significant differences in the Total clinical Efficiency (mean difference (MD) = 4.62, 95% Confidence Interval (CI) = 3.52-6.08, P < .01), WOMAC score (MD = 6.57, 95% CI = 5.78-7.36, P < .01), VAS score (MD = 0.26, 95% CI = 0.14-0.37, P < .0001), Lysholm scores (MD = 5.21, 95% CI = 4.51-5.90, P < .0001), and Lequesne index (MD = 5.21, 95% CI = 4.51-5.90, P < .0001) between the Traditional Chinese Medicine External Treatment combined with sodium vitrate injection group and control group.| | ^Results| A total of 3239 patients from 31 RCTs were finally included. Meta-analysis showed significant differences in the Total clinical Efficiency (mean difference (MD) = 4.62, 95% Confidence Interval (CI) = 3.52-6.08, P < .01), WOMAC score (MD = 6.57, 95% CI = 5.78-7.36, P < .01), VAS score (MD = 0.26, 95% CI = 0.14-0.37, P < .0001), Lysholm scores (MD = 5.21, 95% CI = 4.51-5.90, P < .0001), and Lequesne index (MD = 5.21, 95% CI = 4.51-5.90, P < .0001) between the Traditional Chinese Medicine External Treatment combined with sodium vitrate injection group and control group.| | ||
| ^Conclusion| The efficacy of traditional Chinese external treatment combined with sodium vitrate injection for osteoarthritis of the knee was superior to that of sodium vitrate injection only in all cases. Due to the limitations of the quantity and quality of the included literature, more high-quality literature is needed to validate this conclusion at a later stage.| | ^Conclusion| The efficacy of traditional Chinese external treatment combined with sodium vitrate injection for osteoarthritis of the knee was superior to that of sodium vitrate injection only in all cases. Due to the limitations of the quantity and quality of the included literature, more high-quality literature is needed to validate this conclusion at a later stage.| | ||
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| + | === Combined with active exercise training === | ||
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| + | == Chen 2023 == | ||
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| + | Chen J, Guo H, Pan J, Li H, Wang Y, Liu Z, Xie Y, Jin S. Efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis individuals: a systematic review and meta-analysis. J Orthop Surg Res. 2023 Dec 2;18(1):921. https://doi.org/10.1186/s13018-023-04403-2 | ||
| + | ^Objective| To conduct a systematic review and meta-analysis to investigate the clinical efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis (KOA) individuals.| | ||
| + | ^Methods| Data sources. PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang Data, Technology Periodical Database and China Biology Medicine were searched from their inceptions to April 5, 2023. Review methods: We analyzed trials of acupuncture combined with active exercise training for KOA. The included studies were of high quality (Jadad ≥ 4) and RCTs. Study selection, data extraction, risk of bias and quality assessment were independently performed by two reviewers. We performed systematic analyses based on different outcome measures, including total efficiency rate, visual analogue scale (VAS), the Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC), the Lysholm Knee Scale (LKS) and range of motion (ROM). We used Review Manager 5.3 and Stata/MP 14.0 to analyze the data. And it was verified by trial sequence analysis (TSA). If I2 > 50% and p < 0.05, we performed sensitivity analysis and subgroup analysis to find the source of heterogeneity. Publication bias was studied by funnel plot and Egger’s test was used to verify it.| | ||
| + | ^Results| Full **11 high-quality studies** (Jadad ≥ 4) including 774 KOA individuals were included in this review for meta-analysis. The results showed that acupuncture combined with active exercise training (combined group) was superior to the acupuncture group in improving the total effective rate [RR = 1.13, 95%CI (1.05, 1.22), I2 = 0%, P = 0.70], reducing the pain level (VAS) [MD = − 0.74, 95%CI (− 1.04, − 0.43), I2 = 68%, P < 0.05], improving knee joint function (WOMAC) [MD = − 6.97, 95%CI (− 10.74, − 3.19), I2 = 76%, P < 0.05] and improving joint range of motion (ROM) [MD = 6.25, 95%CI (2.37, 10.04), I2 = 0%, P = 0.71]. Similarly, the combined group showed significant improvements in the total effective rate [RR = 1.31, 95% CI (1.18, 1.47), I2 = 48%, P = 0.10], pain (VAS) [MD = 1.42, 95% CI (− 1.85, − 1.00), I2 = 65%, P = 0.02] and knee function (WOMAC) [MD = 7.05, 95% CI (− 11.43, − 2.66), I2 = 86%, P < 0.05] compared with the non-acupuncture group.| | ||
| + | ^Conclusion| The combined effect of all studies showed significant benefits of acupuncture combined with active exercise training in improving the total effective rate, reducing pain, promoting recovery of knee function and expanding range of motion. However, some evaluation indicators are highly subjective and need to be further confirmed by more objective and evidence-based high-quality RCTs in future.| | ||
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| === Combined with manipulation === | === Combined with manipulation === | ||
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| + | == Wu 2023 (combined with sodium hyaluronate) == | ||
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| + | Wu Q, Wu Z, Lu Z. Efficacy of acupotomy combined with sodium hyaluronate versus sodium hyaluronate alone in the treatment of knee osteoarthritis: A meta-analysis. Medicine (Baltimore). 2023 Sep 15;102(37):e34930. https://doi.org/10.1097/MD.0000000000034930. | ||
| + | ^Background| The efficacy of acupotomy combined with hyaluronic sodium acid in the treatment of knee osteoarthritis (KOA) is unclear. Therefore, this meta-analysis aims to evaluate the efficacy of acupotomy combined with hyaluronic sodium acid compared with hyaluronic sodium acid alone in the treatment of KOA.| | ||
| + | ^Methods| Studies from 8 Online databases were searched on KOA treatment using acupotomy combined with sodium hyaluronate until May 2022. The primary outcome indicator was clinical effectiveness, and the secondary outcome indicators included the visual analogue scale scores and Lysholm scores. We calculated the weighted mean difference (WMD) or relative risk for all relevant outcomes.| | ||
| + | ^Results| **Nine studies were identified, involving 644 cases**. The results showed that acupotomy combined with intra-articular sodium hyaluronate injection for KOA was superior to sodium hyaluronate injection alone in terms of clinical effectiveness (relative risk = 1.17, 95% confidence interval [CI]: 1.09-1.25, P < .001) and visual analogue scale (WMD = -2.1, 95% CI: -2.25 to 1.95, P < .001), Lysholm score (WMD = 13.83, 95% CI: 3.47-24.19, P = .009).| | ||
| + | ^Conclusion| Acupotomy combined with intra-articular sodium hyaluronate injection for KOA is superior to sodium hyaluronate injection alone. Limited by the number and quality of included studies, this conclusion still needs to be verified by more high-quality Research.| | ||
| == Yin 2022 == | == Yin 2022 == | ||
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| Shi X, Yu W, Zhang W, Wang T, Battulga O, Wang L, Guo C. A comparison of the effects of electroacupuncture versus transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: a Bayesian network meta-analysis of randomized controlled trials. Acupuncture in Medicine. 2021;39(3):163-174. [221950]. https://doi.org/10.1177/0964528420921193 | Shi X, Yu W, Zhang W, Wang T, Battulga O, Wang L, Guo C. A comparison of the effects of electroacupuncture versus transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: a Bayesian network meta-analysis of randomized controlled trials. Acupuncture in Medicine. 2021;39(3):163-174. [221950]. https://doi.org/10.1177/0964528420921193 | ||
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| - | ^Background| To compare the effectiveness of electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) for pain control in knee osteoarthritis (KOA). | | + | ^Background|To compare the effectiveness of electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) for pain control in knee osteoarthritis (KOA). | |
| ^Methods|Four English (MEDLINE, EMBASE, Cochrane Library and Web of Science) and three Chinese (China Science Journal Citation Report (VIP), Wanfang and China National Knowledge Infrastructure (CNKI)) language databases were searched for eligible randomized controlled trials (RCTs), comparing four approaches: EA, TENS, medication and sham/placebo controls. The primary outcome was pain intensity, measured by visual analogue scale (VAS), numeric-rating scale (NRS) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale. Classic pairwise and Bayesian network meta-analyses were conducted to integrate the treatment efficacy/effectiveness through direct and indirect evidence. | | ^Methods|Four English (MEDLINE, EMBASE, Cochrane Library and Web of Science) and three Chinese (China Science Journal Citation Report (VIP), Wanfang and China National Knowledge Infrastructure (CNKI)) language databases were searched for eligible randomized controlled trials (RCTs), comparing four approaches: EA, TENS, medication and sham/placebo controls. The primary outcome was pain intensity, measured by visual analogue scale (VAS), numeric-rating scale (NRS) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale. Classic pairwise and Bayesian network meta-analyses were conducted to integrate the treatment efficacy/effectiveness through direct and indirect evidence. | | ||
| ^Results|Thirteen studies were included. In the direct meta-analyses, there was no statistically significant overall effect of EA (mean difference (MD) -4.77, 95% confidence interval (CI) -12.51 to 2.96), while the overall effects of high-frequency transcutaneous electrical nerve stimulation (H-TENS) (MD -16.63, 95% CI -24.57 to -8.69) and medication (MD -7.12, 95% CI -12.07 to -2.17) were statistically significant. In the network meta-analyses, the relative effect of the EA and H-TENS groups (MD 5.07, 95% CI -11.33 to 21.93) on pain control did not differ. Meanwhile, H-TENS demonstrated the highest probability of being the first best treatment, and EA had the second highest probability. | | ^Results|Thirteen studies were included. In the direct meta-analyses, there was no statistically significant overall effect of EA (mean difference (MD) -4.77, 95% confidence interval (CI) -12.51 to 2.96), while the overall effects of high-frequency transcutaneous electrical nerve stimulation (H-TENS) (MD -16.63, 95% CI -24.57 to -8.69) and medication (MD -7.12, 95% CI -12.07 to -2.17) were statistically significant. In the network meta-analyses, the relative effect of the EA and H-TENS groups (MD 5.07, 95% CI -11.33 to 21.93) on pain control did not differ. Meanwhile, H-TENS demonstrated the highest probability of being the first best treatment, and EA had the second highest probability. | | ||
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| | **Acupuncture**: (Evidence level: Level I, highly recommended). **Acupotomy**:Evidence level: Level II, highly recommended).| | | **Acupuncture**: (Evidence level: Level I, highly recommended). **Acupotomy**:Evidence level: Level II, highly recommended).| | ||
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| + | ==== Hong Kong Physiotherapy Association (HKPA, Hong Kong, China) 2023 ⊕ ==== | ||
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| + | Al Zoubi FM, Wong AYL, Cheing GLY, Cheung JPY, Fu SN, Tsang HHL, Law RKY, So BCL, Tsang R, Tsang S, Wen C, Wong M, Yau YC, Bussières AE. Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists. Healthcare (Basel). 2023 Nov 15;11(22):2964. https://doi.org/10.3390/healthcare11222964 | ||
| + | | Acupuncture : conditionnaly recommanded | | ||
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| ==== American Academy of Orthopaedic Surgeons (AAOS, USA) 2021 ⊕==== | ==== American Academy of Orthopaedic Surgeons (AAOS, USA) 2021 ⊕==== | ||
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| |Anterior Knee Pain. There are no randomised controlled studies evaluating the effect of acupuncture for relief of patellofemoral pain (No Level I or II evidence)| | |Anterior Knee Pain. There are no randomised controlled studies evaluating the effect of acupuncture for relief of patellofemoral pain (No Level I or II evidence)| | ||
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| + | ===== Overviews of Clinical Practice Guidelines ===== | ||
| + | ==== Gibbs 2023 ==== | ||
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| + | Gibbs AJ, Gray B, Wallis JA, Taylor NF, Kemp JL, Hunter DJ, Barton CJ. Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis Cartilage. 2023 Oct;31(10):1280-1292. https://doi.org/10.1016/j.joca.2023.05.015 | ||
| + | ^Objectives| Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.| | ||
| + | ^Methods| Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).| | ||
| + | ^Results| **Seven higher-quality and 18 lesser-quality guidelines** were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., **acupuncture**) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.| | ||
| + | ^Conclusion| Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.| | ||
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